Mitral valve rupture during percutaneous dilation of aortic valve stenosis

Transcatheter aortic valve implantation for high risk patients with severe aortic stenosis using the Edwards Sapien balloon-expandable bioprosthesis: a single centre study with immediate and medium-term outcomes

BACKGROUND

Transcatheter aortic valve implantation (TCAVI) is an emerging alternative therapy to open-heart surgery in high-risk patients with symptomatic aortic stenosis.

METHODS

Between January 2007 and May 2009, 46 patients underwent TCAVI with the 23 mm or 26 mm Edwards Sapien bioprosthesis via either the transapical (TA-AVI) or transfemoral (TF-AVI) approach. All patients had an estimated operative mortality risk of >15%.

RESULTS

A total of 46 patients (30 TA-AVI, 16 TF-AVI) with a mean aortic valve area (AVA) of 0.63 +/- 0.2 cm(2) and mean gradient of 54 +/- 16 mm Hg were treated. Predicted operative mortality was 25.3% by logistic Euroscore and 8.7% by Society of Thoracic Surgeons risk score. Procedural success was 93% in the TA-AVI group and 88% in the TF-AVI group. There was one intraprocedural death in the TA-AVI group. Overall 30-day mortality was 6.5% (2-TA-AVI, 1-TF-AVI). Four patients (9.5%) died from noncardiac causes after 30 days. Successful TCAVI was associated with a significant increase in AVA from 0.6 +/- 0.1 cm(2) to 1.6 +/- 0.6 cm(2) in the TA-AVI group and 0.6 +/- 0.1 cm(2) to 1.4 +/- 0.2 cm(2) in the TF-AVI group at a mean follow up of 7.4 +/- 4.4 and 8.3 +/- 5.0 months, respectively. At discharge, there was significant improvement in AVA (P < 0.0001), transaortic mean gradient (P < 0.0001), and mitral regurgitation (P = 0.01). At medium term follow up, the valve area was maintained and there was significant improvement in NYHA class in both groups (P < 0.0001).

CONCLUSION

At medium term follow-up, both transcatheter approaches demonstrated good valve durability with no cardiac-related mortality post hospital discharge.

Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry

BACKGROUND

Percutaneous balloon aortic valvuloplasty has been used as a therapeutic option for relief of valvular stenosis. This study describes patients undergoing initial percutaneous aortic balloon valvuloplasty enrolled in the National Heart, Lung, and Blood Institute (NHLBI) Balloon Valvuloplasty Registry.

METHODS AND RESULTS

Extensive baseline procedural and postprocedural data were tabulated in 674 patients during a 24-month period. Functional status was captured using standard methods and an overall functional scoring system. Complications were defined and divided into procedural, acute (within 24 hours), in-hospital, and within 30 days of the procedure. The patient population was elderly and symptomatic, with 83% greater than 70 years of age. New York Heart Association functional class (FC) III or IV congestive heart failure (CHF) was present in 76%, syncope or presyncope was present in 34%, and Canadian Heart Association class III or IV angina was present in 23%. Using an overall functional scoring system (0-100), 54% exhibited scores less than 50. Comorbid disease was common. Forty-five percent possessed at least one serious noncardiac disability as a reason for valvuloplasty. Eighty percent of those seen by a cardiothoracic surgeon were believed inappropriate for aortic valve replacement. Hemodynamically, the aortic valve area increased from 0.5 +/- 0.2 cm2 to 0.8 +/- 0.3 cm2 (p less than 0.0001), accompanied by a fall in mean and peak aortic valve gradient from 55 +/- 21 and 65 +/- 28 mm Hg to 29 +/- 13 and 31 +/- 18 mm Hg, respectively (both p less than 0.0001). Small but significant increases were observed in cardiac output, heart rate, and mean aortic pressure with minor declines in the pulmonary artery (PA) systolic and left ventricular (LV) end-diastolic pressure. One hundred sixty-seven (25%) experienced at least one significant complication within 24 hours, and 211 (31%) experienced a significant complication before discharge. Complications before hospital discharge included the need for transfusion (23%), vascular surgery (7%), cerebrovascular accident (3%), other systemic embolus (2%), myocardial infarction (2%), acute tubular necrosis (1%), or cardiac surgery (1%). Seventeen (3%) patients died during the procedure; 16 of those were due to cardiac causes. By hospital discharge, there was an additional 52 total deaths; 37 were due to cardiovascular causes. Between hospital discharge and 30 days, 23 additional deaths occurred; 18 were due to cardiac disease. At 30 days, therefore, there was a grand total of 92 (14%) deaths; 71 (11%) were due to cardiovascular-related causes. Univariate and logistic regression analysis of mortality revealed that death was most frequent in patients suffering multiorgan failure and poor LV systolic function. Thirty-day mortality was associated with a predefined high-risk subset of hypotension and NYHA class IV CHF (risk ratio, 4.4), blood urea nitrogen (BUN) greater than 30 mg/dl (risk ratio, 3.7), use of an antiarrhythmic (risk ratio, 2.9), and cardiac output less than 3.0 l/min (risk ratio, 2.4). Of the survivors (86%) at 30 days, symptomatic improvement was generally present. Seventy-five percent experienced at least one functional class improvement in CHF, and 53% experienced at least a quartile improvement in overall functional status score.

CONCLUSIONS

These data reveal that percutaneous aortic balloon valvuloplasty in an elderly and debilitated population can be done with low mortality but substantial morbidity. Mortality is greatest in patients with multiorgan failure resulting from poor cardiac output. In patients with reasonably preserved LV function who are otherwise inappropriate surgical candidates because of comorbid factors, survival and early improvement in symptomatic status are frequently observed after percutaneous aortic valvuloplasty.